ASG

1. Referral:

“Jezabel” is an adult, female spayed domestic shorthair who presented to us for a 1 week history of decreased appetite. The owner adopted Jezabel about 13 years prior, and he is unsure of her age at that time. She had been previously completely healthy, but stopped eating about a week before presentation. She vomited up some foamy material, but no other clinical signs were present. She went to her family veterinarian where bloodwork and an abdominal ultrasound were done. Her bloodwork showed a mildly increased potassium (5.7mmol/L) and no other abnormalities. The ultrasound showed a mass along the lesser curvature of the stomach with possible complete erosion through the gastric wall.

2. Exam:

Jezabel’s physical exam revealed a mildly dehydrated cat with a good body condition score (5/9). Her heart and lungs ausculted normally and her neurologic exam was unremarkable. On abdominal palpation, there was a firm mass in the cranial abdomen, about 4cm in diameter. She was only mildly painful on palpation, especially when concentrating on the mass.

We talked to the owner at length about gastric masses, with the most common tumors in cats being lymphoma and adenocarcinoma. We discussed repeating the ultrasound to better determine how much of the stomach was involved, if there was evidence of perforation (free gas or fluid), and to possibly obtain a fine needle aspirate of the mass to get a diagnosis without surgery. The other option was to do an exploratory laparotomy, with both diagnostic and therapeutic goals. We explained to the owner that there was a possibility that surgery would reveal a disease process so advanced that surgical intervention would not help Jezabel at all, and he should consider whether or not he would want to continue if the initial surgical findings were catastrophic. Her owner elected to proceed with surgical exploration and treatment if possible.

3. Procedures:

During anesthetic induction, Jezabel’s Doppler blood pressure dropped to 40mmHg. She responded only mildly to crytalloid and colloid boluses, and was started on vasopressor support and switched from inhalant anesthesia to all injectible anesthesia with propofol, ketamine and fenanyl continuous rate infusions. The severe hypotension led us to believe that there was indeed a complete perforation in the stomach wall, and Jezabel had leakage of gastric contents.

Upon entering her abdomen, our suspicions were confirmed. There was a 4cm firm mass at the junction of the esophagus and stomach, with a 1.5cm hole in the middle of it, actively leaking gastric contents. The owner was called to inform him of the severity of the situation, and he needed some time to discuss the matter with his wife. While waiting for his return call, we initiated a gastroesophageal resection and anastomosis to fully excise the lesion. By the time he called back, we were about halfway done with the procedure, and he decided to have us continue. With complete excision of the lesion, we also had to remove the lower esophageal sphincter. Once the resection and anastomosis was complete and the mass was submitted for histopathologic interpretation, a gastrostomy tube was placed to initiate nutritional support as soon as possible.

4. Diagnosis:

Histopathology revealed feline gastrointestinal eosinophilic sclerosing fibroplasia, with no evidence of cancer.

5. Treatment:

After surgical excision of the lesion, anastomosis of the stomach to the esophagus, and placement of the gastrostomy tube, treatment was focused on maintaining adequate blood pressure, starting nutritional support, and preventing reflux of gastric contents into the esophagus. Without the presence of a lower esophageal sphincter, our main concern was continual reflux and resulting ulceration that would lead to a poor quality of life. Jezabel was started on broad spectrum antibiotics, gastrointestinal protectants (sucralfate, pantoprazole), and promotility agents (metoclopramide, erythromycin). She was maintained on her vasopressor support due to persistant hypotension until she was able to be weaned off of these medications. Nutritional support was started within 4 hours of surgery with a continuous rate infusion of Vital HN and a well-balanced elemental liquid diet. She started eating small amounts on her own after 4-5 days, and was discharged about 8 days after surgery.

6. Discussion:

Feline gastrointestinal eosinophilic sclerosing fibroplasia is a poorly understood and uncommon finding. In an article from Veterinary Pathology from 2009, Craig et al describe this disease process in 25 cats. The main findings from the paper include lesion localization (most commonly in the pyloric region), survival data (0 days-2 years), and treatment recommendations (cats treated with prednisone survived longer than those treated with antibiotics). Many of the patients were euthanized during surgery due to the severity of the lesion and the suspicion of the presence of neoplasia. Many of the biopsies revealed presence of helicobacter, and thus we treated with borad-spectrum antibiotics known to have good efficacy against this organism.

Initiation of early enteral nutrition was crucial, both supplying much needed protein for effective healing, and supporting enterocytes locally for successful anastomosis. The presence of the gastrostomy tube allowed not only feeding and medication delivery, but also monitoring of gastric residuals to evaluate the effectiveness of our promotility agents. Protection against esophageal ulceration with a proton pump inhibitor and sucralfate was also a high priority. Without the lower esophageal sphincter, there was minimal prevention of reflux of gastric contents.

7. Recovery:

Jezabel is doing well at home, having only intermittent bouts of vomiting. She is eating all on her own, and the gastrostomy tube will be removed soon. She will continue on a proton pump inhibitor for life, and will be administered sucralfate if she has bouts of vomiting or regurgitation. Based on the literature, the gastrointestinal eosinophilic sclerosing fibroplasia will be treated with prednisolone in hopes of controlling the inflammation and preventing recurrence.

by Adam Strom,
DVM, MS Diplomate American College of Veterinary Surgeons

REFERENCE: Craig LE, Hardam EE, Hertzke DM, et al: Feline gastrointestinal eosinophilic sclerosing fibroplasia. Vet Pathol 49: 63-70, 2009.

*Photo of cat is not “Jezabel.”